Provider Demographics
NPI:1598116139
Name:AGONAFER, EDDEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EDDEN
Middle Name:
Last Name:AGONAFER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 LILAC CANYON LN
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3870
Mailing Address - Country:US
Mailing Address - Phone:254-214-9431
Mailing Address - Fax:
Practice Address - Street 1:3855 LILAC CANYON LN
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3870
Practice Address - Country:US
Practice Address - Phone:254-214-9431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA31122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program